Heidi Splete

CHICAGO — Assume noncompliance when treating atopic dermatitis in teenage patients, said Dr. Jon M. Hanifin, a dermatologist at Oregon Health and Science University in Portland.

“Managing atopic dermatitis in teenagers is not for the faint of heart,” said Dr. Hanifin, a specialist in atopic dermatitis who has served as a consultant for multiple pharmaceutical companies.

Dr. Hanifin shared some tips on treating atopic dermatitis (AD) in teenagers at the annual meeting of the Society for Pediatric Dermatology. His advice included the following:

▸ Keep the parents out of the room except for the start and end of the visit. “You have to get the parents out of the room to find out what's going on,” he said.

▸ Ask the teens to call the office if the treatment isn't going well and encourage them to schedule their appointments.

▸ Offer psychiatric consultation. Some of these teens genuinely want help other than their parents yelling at them.

▸ Don't shy away from systemic medications. Try methotrexate for moderate to severe cases of AD in adolescents because it is less expensive than cyclosporin, Dr. Hanifin said.

He said he often starts teen atopic dermatitis patients with 2.5 mg of methotrexate for 4 of 7 days each week, which has been more effective than a once weekly dose of 15 mg in many of his teen patients. “For the really severe cases, I'll increase the dose [of methotrexate] to 5 mg, and when remission occurs we'll go through the same pattern of tapering that we would with cyclosporin.”

But clinicians should remember that teenagers are prone to rebellion, and they will try everything else they think might work except what parents and doctors advise them to do, he warned.

For a busy teenager, making time for consistent AD care is rarely a priority, he noted.

CHICAGO — Assume noncompliance when treating atopic dermatitis in teenage patients, said Dr. Jon M. Hanifin, a dermatologist at Oregon Health and Science University in Portland.

“Managing atopic dermatitis in teenagers is not for the faint of heart,” said Dr. Hanifin, a specialist in atopic dermatitis who has served as a consultant for multiple pharmaceutical companies.

Dr. Hanifin shared some tips on treating atopic dermatitis (AD) in teenagers at the annual meeting of the Society for Pediatric Dermatology. His advice included the following:

▸ Keep the parents out of the room except for the start and end of the visit. “You have to get the parents out of the room to find out what's going on,” he said.

▸ Ask the teens to call the office if the treatment isn't going well and encourage them to schedule their appointments.

▸ Offer psychiatric consultation. Some of these teens genuinely want help other than their parents yelling at them.

▸ Don't shy away from systemic medications. Try methotrexate for moderate to severe cases of AD in adolescents because it is less expensive than cyclosporin, Dr. Hanifin said.

He said he often starts teen atopic dermatitis patients with 2.5 mg of methotrexate for 4 of 7 days each week, which has been more effective than a once weekly dose of 15 mg in many of his teen patients. “For the really severe cases, I'll increase the dose [of methotrexate] to 5 mg, and when remission occurs we'll go through the same pattern of tapering that we would with cyclosporin.”

But clinicians should remember that teenagers are prone to rebellion, and they will try everything else they think might work except what parents and doctors advise them to do, he warned.

For a busy teenager, making time for consistent AD care is rarely a priority, he noted.

CHICAGO — Assume noncompliance when treating atopic dermatitis in teenage patients, said Dr. Jon M. Hanifin, a dermatologist at Oregon Health and Science University in Portland.

“Managing atopic dermatitis in teenagers is not for the faint of heart,” said Dr. Hanifin, a specialist in atopic dermatitis who has served as a consultant for multiple pharmaceutical companies.

Dr. Hanifin shared some tips on treating atopic dermatitis (AD) in teenagers at the annual meeting of the Society for Pediatric Dermatology. His advice included the following:

▸ Keep the parents out of the room except for the start and end of the visit. “You have to get the parents out of the room to find out what's going on,” he said.

▸ Ask the teens to call the office if the treatment isn't going well and encourage them to schedule their appointments.

▸ Offer psychiatric consultation. Some of these teens genuinely want help other than their parents yelling at them.

▸ Don't shy away from systemic medications. Try methotrexate for moderate to severe cases of AD in adolescents because it is less expensive than cyclosporin, Dr. Hanifin said.

He said he often starts teen atopic dermatitis patients with 2.5 mg of methotrexate for 4 of 7 days each week, which has been more effective than a once weekly dose of 15 mg in many of his teen patients. “For the really severe cases, I'll increase the dose [of methotrexate] to 5 mg, and when remission occurs we'll go through the same pattern of tapering that we would with cyclosporin.”

But clinicians should remember that teenagers are prone to rebellion, and they will try everything else they think might work except what parents and doctors advise them to do, he warned.

For a busy teenager, making time for consistent AD care is rarely a priority, he noted.

MIAMI – A few changes can make a practice more welcoming to lesbian patients, Dr. Christy Isler said at the annual meeting of the American College of Preventive Medicine.

Being mindful and inclusive in words and actions (as well as reminding your staff to do likewise) can go a long way toward helping patients feel comfortable, while also boosting the likelihood that they'll return for regular visits, said Dr. Isler, who is an ob.gyn. and maternal-fetal medicine specialist at East Carolina University in Greenville, N.C.

Dr. Isler offered the following advice:

▸ Don't presume a person's sexuality based on appearance, demeanor, or profession. Revise forms to include options for “partnered” in addition to the usual choices of single, married, divorced, or widowed. Use terms such as “partner's name” rather than “spouse's name.”

Make sure the partner's name is on the patient's information form, because that partner may be the emergency contact for that patient.

▸ Post a nondiscrimination policy where all patients can see it. But also note that patients' confidentiality on all health issues is respected and protected.

▸ Ask patients whether they are sexually active with men, with women, or with both.

▸ Ask an individual about her partner the same way you would ask any woman how her family is doing. Remember that for many lesbian patients, their partners are their chosen families, and they may have little or no relationship with their biological families.

▸ Remember that a regular visit for a lesbian patient includes the same preventive medicine issues as for any other female patient: diet, exercise, alcohol use, smoking, reproductive issues, and domestic violence.

▸ Be aware of a possible increased risk of psychological problems among lesbians. Ask about stress levels and refer for additional help as needed to address mental and emotional health issues.

MIAMI – A few changes can make a practice more welcoming to lesbian patients, Dr. Christy Isler said at the annual meeting of the American College of Preventive Medicine.

Being mindful and inclusive in words and actions (as well as reminding your staff to do likewise) can go a long way toward helping patients feel comfortable, while also boosting the likelihood that they'll return for regular visits, said Dr. Isler, who is an ob.gyn. and maternal-fetal medicine specialist at East Carolina University in Greenville, N.C.

Dr. Isler offered the following advice:

▸ Don't presume a person's sexuality based on appearance, demeanor, or profession. Revise forms to include options for “partnered” in addition to the usual choices of single, married, divorced, or widowed. Use terms such as “partner's name” rather than “spouse's name.”

Make sure the partner's name is on the patient's information form, because that partner may be the emergency contact for that patient.

▸ Post a nondiscrimination policy where all patients can see it. But also note that patients' confidentiality on all health issues is respected and protected.

▸ Ask patients whether they are sexually active with men, with women, or with both.

▸ Ask an individual about her partner the same way you would ask any woman how her family is doing. Remember that for many lesbian patients, their partners are their chosen families, and they may have little or no relationship with their biological families.

▸ Remember that a regular visit for a lesbian patient includes the same preventive medicine issues as for any other female patient: diet, exercise, alcohol use, smoking, reproductive issues, and domestic violence.

▸ Be aware of a possible increased risk of psychological problems among lesbians. Ask about stress levels and refer for additional help as needed to address mental and emotional health issues.

MIAMI – A few changes can make a practice more welcoming to lesbian patients, Dr. Christy Isler said at the annual meeting of the American College of Preventive Medicine.

Being mindful and inclusive in words and actions (as well as reminding your staff to do likewise) can go a long way toward helping patients feel comfortable, while also boosting the likelihood that they'll return for regular visits, said Dr. Isler, who is an ob.gyn. and maternal-fetal medicine specialist at East Carolina University in Greenville, N.C.

Dr. Isler offered the following advice:

▸ Don't presume a person's sexuality based on appearance, demeanor, or profession. Revise forms to include options for “partnered” in addition to the usual choices of single, married, divorced, or widowed. Use terms such as “partner's name” rather than “spouse's name.”

Make sure the partner's name is on the patient's information form, because that partner may be the emergency contact for that patient.

▸ Post a nondiscrimination policy where all patients can see it. But also note that patients' confidentiality on all health issues is respected and protected.

▸ Ask patients whether they are sexually active with men, with women, or with both.

▸ Ask an individual about her partner the same way you would ask any woman how her family is doing. Remember that for many lesbian patients, their partners are their chosen families, and they may have little or no relationship with their biological families.

▸ Remember that a regular visit for a lesbian patient includes the same preventive medicine issues as for any other female patient: diet, exercise, alcohol use, smoking, reproductive issues, and domestic violence.

▸ Be aware of a possible increased risk of psychological problems among lesbians. Ask about stress levels and refer for additional help as needed to address mental and emotional health issues.

ATLANTA – The vaccine financing system in the United States continues to derail vaccinations for underinsured children and adolescents, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who gave results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee. “In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults. “Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers. The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. Respondents cited insufficient state funding as a primary barrier to vaccination and reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states, 3 designated all public VFC providers, and 1 state manager designated all public and private VFC providers as FQHCs.

Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said. But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte of the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP.

For up-to-date information on FQHCcoverage, billing, and policies, visit www.cms.hhs.gov/center/fqhc.asp

ATLANTA – The vaccine financing system in the United States continues to derail vaccinations for underinsured children and adolescents, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who gave results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee. “In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults. “Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers. The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. Respondents cited insufficient state funding as a primary barrier to vaccination and reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states, 3 designated all public VFC providers, and 1 state manager designated all public and private VFC providers as FQHCs.

Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said. But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte of the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP.

For up-to-date information on FQHCcoverage, billing, and policies, visit www.cms.hhs.gov/center/fqhc.asp

ATLANTA – The vaccine financing system in the United States continues to derail vaccinations for underinsured children and adolescents, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who gave results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee. “In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults. “Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers. The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. Respondents cited insufficient state funding as a primary barrier to vaccination and reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states, 3 designated all public VFC providers, and 1 state manager designated all public and private VFC providers as FQHCs.

Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said. But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte of the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP.

For up-to-date information on FQHCcoverage, billing, and policies, visit www.cms.hhs.gov/center/fqhc.asp

MINNEAPOLIS — Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires, including the Epworth Sleepiness Scale, to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors—snoring, sleepiness, and obesity/hypertension—were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did controls.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours vs. 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes vs. 18.6 minutes), compared with controls

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136–8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after decompressive surgery, Dr. Watson said.

MINNEAPOLIS — Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires, including the Epworth Sleepiness Scale, to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors—snoring, sleepiness, and obesity/hypertension—were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did controls.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours vs. 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes vs. 18.6 minutes), compared with controls

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136–8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after decompressive surgery, Dr. Watson said.

MINNEAPOLIS — Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires, including the Epworth Sleepiness Scale, to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors—snoring, sleepiness, and obesity/hypertension—were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did controls.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours vs. 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes vs. 18.6 minutes), compared with controls

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136–8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after decompressive surgery, Dr. Watson said.

MINNEAPOLIS — Two dopamine agonists—pramipexole and ropinirole—each improved symptoms and quality of life in adults with restless legs syndrome, based on data from studies presented at the annual meeting of the Associated Professional Sleep Societies. Both drugs are approved by the Food and Drug Administration for the treatment of restless legs syndrome.

Patients with restless legs syndrome (RLS) often report uncomfortable sensations deep in their legs accompanied by irresistible urges to move their legs. The symptoms worsen at night and tend to disrupt sleep, which has a negative impact on patients' quality of life.

Data from three randomized, double-blind, placebo-controlled studies of pramipexole showed that those who received the drug reported significant improvements in quality of life and in RLS symptoms, compared with placebo patients. The dosage used in the three studies ranged from 0.125 mg/day to 0.75 mg/day. The studies included a total of 784 adults (aged 18–79 years; average age 51 years); all patients met the diagnosis for RLS and had at least one postbaseline evaluation. All three studies were supported by Boehringer Ingelheim Pharmaceuticals Inc.

In the largest of the three studies, the 258 patients randomized to receive pramipexole for 12 weeks reported significant improvements in sleep quality, shorter time to fall asleep, and improved daytime symptoms, compared with 86 patients who received a placebo. Based on visual analog scale scores, daytime symptom severity improved by 49% in the pramipexole group, compared with 32% in the placebo group, and pramipexole patients reported an average of 57% improvement in sleep satisfaction, vs. 38% in the placebo group. The study was conducted by Dr. Robert D. Ballard of the University of Colorado Health Sciences Center in Denver.

Pramipexole did not increase daytime sleepiness, compared with placebo, across these three studies. In fact, the pramipexole patients who reported abnormal daytime sleepiness at baseline reported significant improvement in daytime sleepiness, compared with placebo patients, based on the Epworth Sleepiness Scale. No significant differences appeared in daytime sleepiness among patients in the two groups that reported normal levels of daytime sleepiness at baseline.

In a pair of similar studies of ropinirole, presented by Dr. Markus H. Schmidt of the Ohio Sleep Medicine Institute in Dublin, Ohio, the drug significantly improved the symptoms of restless legs syndrome and improved patients' quality of life in a randomized trial with an intent-to-treat population of 382 adults with RLS. The daily dose ranged from 0.5 to 6.0 mg, titrated as needed. Dr. Schmidt has received financial support from and has served as a speaker for GlaxoSmithKline, the company that supported the research.

After 12 weeks, the 187 patients who received ropinirole reported significantly greater improvements in symptoms, compared with the 195 placebo patients, in four areas of the Medical Outcomes Study Sleep Scale (reduction in sleep disturbance, reduction in daytime sleepiness, increased sleep adequacy, and increased sleep quantity). Adverse events were mild to moderate, and only 4% of the ropinirole patients and 3% of the placebo patients discontinued the medications because of adverse events. The most often reported adverse events in the ropinirole group vs. the placebo group were nausea (28% vs. 7%), headache (20% vs. 18%), and sleepiness (9% vs. 6%).

After treatment, nearly half (49%) of the ropinirole patients were classified as “not ill” or “borderline ill,” compared with 31% of placebo patients, based on a clinician-rated scale. In addition, significantly more patients showed improvement in illness based on a patient-rated scale at 2 days, 3 days, and 4 days after starting treatment. On day 4, 42% of the ropinirole patients were classified as responders, compared with 24% of the placebo patients.

MINNEAPOLIS — Two dopamine agonists—pramipexole and ropinirole—each improved symptoms and quality of life in adults with restless legs syndrome, based on data from studies presented at the annual meeting of the Associated Professional Sleep Societies. Both drugs are approved by the Food and Drug Administration for the treatment of restless legs syndrome.

Patients with restless legs syndrome (RLS) often report uncomfortable sensations deep in their legs accompanied by irresistible urges to move their legs. The symptoms worsen at night and tend to disrupt sleep, which has a negative impact on patients' quality of life.

Data from three randomized, double-blind, placebo-controlled studies of pramipexole showed that those who received the drug reported significant improvements in quality of life and in RLS symptoms, compared with placebo patients. The dosage used in the three studies ranged from 0.125 mg/day to 0.75 mg/day. The studies included a total of 784 adults (aged 18–79 years; average age 51 years); all patients met the diagnosis for RLS and had at least one postbaseline evaluation. All three studies were supported by Boehringer Ingelheim Pharmaceuticals Inc.

In the largest of the three studies, the 258 patients randomized to receive pramipexole for 12 weeks reported significant improvements in sleep quality, shorter time to fall asleep, and improved daytime symptoms, compared with 86 patients who received a placebo. Based on visual analog scale scores, daytime symptom severity improved by 49% in the pramipexole group, compared with 32% in the placebo group, and pramipexole patients reported an average of 57% improvement in sleep satisfaction, vs. 38% in the placebo group. The study was conducted by Dr. Robert D. Ballard of the University of Colorado Health Sciences Center in Denver.

Pramipexole did not increase daytime sleepiness, compared with placebo, across these three studies. In fact, the pramipexole patients who reported abnormal daytime sleepiness at baseline reported significant improvement in daytime sleepiness, compared with placebo patients, based on the Epworth Sleepiness Scale. No significant differences appeared in daytime sleepiness among patients in the two groups that reported normal levels of daytime sleepiness at baseline.

In a pair of similar studies of ropinirole, presented by Dr. Markus H. Schmidt of the Ohio Sleep Medicine Institute in Dublin, Ohio, the drug significantly improved the symptoms of restless legs syndrome and improved patients' quality of life in a randomized trial with an intent-to-treat population of 382 adults with RLS. The daily dose ranged from 0.5 to 6.0 mg, titrated as needed. Dr. Schmidt has received financial support from and has served as a speaker for GlaxoSmithKline, the company that supported the research.

After 12 weeks, the 187 patients who received ropinirole reported significantly greater improvements in symptoms, compared with the 195 placebo patients, in four areas of the Medical Outcomes Study Sleep Scale (reduction in sleep disturbance, reduction in daytime sleepiness, increased sleep adequacy, and increased sleep quantity). Adverse events were mild to moderate, and only 4% of the ropinirole patients and 3% of the placebo patients discontinued the medications because of adverse events. The most often reported adverse events in the ropinirole group vs. the placebo group were nausea (28% vs. 7%), headache (20% vs. 18%), and sleepiness (9% vs. 6%).

After treatment, nearly half (49%) of the ropinirole patients were classified as “not ill” or “borderline ill,” compared with 31% of placebo patients, based on a clinician-rated scale. In addition, significantly more patients showed improvement in illness based on a patient-rated scale at 2 days, 3 days, and 4 days after starting treatment. On day 4, 42% of the ropinirole patients were classified as responders, compared with 24% of the placebo patients.

MINNEAPOLIS — Two dopamine agonists—pramipexole and ropinirole—each improved symptoms and quality of life in adults with restless legs syndrome, based on data from studies presented at the annual meeting of the Associated Professional Sleep Societies. Both drugs are approved by the Food and Drug Administration for the treatment of restless legs syndrome.

Patients with restless legs syndrome (RLS) often report uncomfortable sensations deep in their legs accompanied by irresistible urges to move their legs. The symptoms worsen at night and tend to disrupt sleep, which has a negative impact on patients' quality of life.

Data from three randomized, double-blind, placebo-controlled studies of pramipexole showed that those who received the drug reported significant improvements in quality of life and in RLS symptoms, compared with placebo patients. The dosage used in the three studies ranged from 0.125 mg/day to 0.75 mg/day. The studies included a total of 784 adults (aged 18–79 years; average age 51 years); all patients met the diagnosis for RLS and had at least one postbaseline evaluation. All three studies were supported by Boehringer Ingelheim Pharmaceuticals Inc.

In the largest of the three studies, the 258 patients randomized to receive pramipexole for 12 weeks reported significant improvements in sleep quality, shorter time to fall asleep, and improved daytime symptoms, compared with 86 patients who received a placebo. Based on visual analog scale scores, daytime symptom severity improved by 49% in the pramipexole group, compared with 32% in the placebo group, and pramipexole patients reported an average of 57% improvement in sleep satisfaction, vs. 38% in the placebo group. The study was conducted by Dr. Robert D. Ballard of the University of Colorado Health Sciences Center in Denver.

Pramipexole did not increase daytime sleepiness, compared with placebo, across these three studies. In fact, the pramipexole patients who reported abnormal daytime sleepiness at baseline reported significant improvement in daytime sleepiness, compared with placebo patients, based on the Epworth Sleepiness Scale. No significant differences appeared in daytime sleepiness among patients in the two groups that reported normal levels of daytime sleepiness at baseline.

In a pair of similar studies of ropinirole, presented by Dr. Markus H. Schmidt of the Ohio Sleep Medicine Institute in Dublin, Ohio, the drug significantly improved the symptoms of restless legs syndrome and improved patients' quality of life in a randomized trial with an intent-to-treat population of 382 adults with RLS. The daily dose ranged from 0.5 to 6.0 mg, titrated as needed. Dr. Schmidt has received financial support from and has served as a speaker for GlaxoSmithKline, the company that supported the research.

After 12 weeks, the 187 patients who received ropinirole reported significantly greater improvements in symptoms, compared with the 195 placebo patients, in four areas of the Medical Outcomes Study Sleep Scale (reduction in sleep disturbance, reduction in daytime sleepiness, increased sleep adequacy, and increased sleep quantity). Adverse events were mild to moderate, and only 4% of the ropinirole patients and 3% of the placebo patients discontinued the medications because of adverse events. The most often reported adverse events in the ropinirole group vs. the placebo group were nausea (28% vs. 7%), headache (20% vs. 18%), and sleepiness (9% vs. 6%).

After treatment, nearly half (49%) of the ropinirole patients were classified as “not ill” or “borderline ill,” compared with 31% of placebo patients, based on a clinician-rated scale. In addition, significantly more patients showed improvement in illness based on a patient-rated scale at 2 days, 3 days, and 4 days after starting treatment. On day 4, 42% of the ropinirole patients were classified as responders, compared with 24% of the placebo patients.

ATLANTA – Children who had received two doses of varicella vaccine comprised nearly a third of the cases in a varicella outbreak among elementary school children in Arkansas.

“This was one of the largest varicella outbreaks investigated in recent years, and it was the first U.S. outbreak reported with a significant number of two-dose vaccines,” said Adriana Lopez, an epidemiologist with the Centers for Disease Control and Prevention's division of viral diseases.

A total of 85 cases were identified during the outbreak, which occurred among children in prekindergarten through sixth grade in the fall of 2006. Of these, 25 (29%) had received two doses of varicella vaccine, 54 (64%) had received one dose, and 6 (7%) had not received any varicella vaccination. “The moderate level of two-dose coverage was insufficient to prevent the outbreak,” said Ms. Lopez, who presented the results at a meeting of the CDC's Advisory Committee on Immunization Practices (ACIP).

Overall, the school's varicella vaccination coverage was 97% among 758 children and 41% of the vaccinated children had received two doses. The CDC was invited to investigate the outbreak in order to confirm varicella in the children who had received two doses of the vaccine and to characterize the vaccine's effectiveness among one- and two-dose recipients. “Disease in vaccinated persons is generally mild, with fewer than 50 lesions and a shorter duration of illness,” noted Ms. Lopez.

For purposes of the investigation, a varicella case was defined as an acute macular papular vesicular rash without another apparent cause. Because of the frequency of insect bites in the region of the outbreak, a child needed at least three lesions to be considered a case.

A total of 27 cases were sampled for testing. Six of these were confirmed as positive using five polymerase chain reaction tests on lesion samples and one using an IgM serum spot test. The positive results for the PCR tests included one child who had received two doses of vaccine, three children who had each received single doses, and one unvaccinated child who had a history of varicella. The positive IgM serum spot test was used for a child who had received one dose of vaccine.

In June 2006, ACIP recommended a routine two-dose varicella vaccination plan for children, with the first dose given at age 12-15 months, the second dose given at age 4-6 years, and catch-up doses given to anyone older than 6 years.

Varicella cases associated with the outbreak were identified by local health data, the school nurse, and through school surveys on vaccination status and disease history. Parents of the children who were identified as cases were contacted and asked for additional information about medical history and vaccination status. Vaccination history was verified using the state's immunization registry, local health records, and the parents' surveys. Children were considered unvaccinated if they had received their first dose of vaccine 42 days or less before they became ill.

“As next steps, additional vaccine effectiveness studies for two doses are needed,” said Ms. Lopez. Data from more than 30 postlicensure studies show effectiveness estimates for a single dose of varicella vaccine ranging from 44% to 100%.

ATLANTA – Children who had received two doses of varicella vaccine comprised nearly a third of the cases in a varicella outbreak among elementary school children in Arkansas.

“This was one of the largest varicella outbreaks investigated in recent years, and it was the first U.S. outbreak reported with a significant number of two-dose vaccines,” said Adriana Lopez, an epidemiologist with the Centers for Disease Control and Prevention's division of viral diseases.

A total of 85 cases were identified during the outbreak, which occurred among children in prekindergarten through sixth grade in the fall of 2006. Of these, 25 (29%) had received two doses of varicella vaccine, 54 (64%) had received one dose, and 6 (7%) had not received any varicella vaccination. “The moderate level of two-dose coverage was insufficient to prevent the outbreak,” said Ms. Lopez, who presented the results at a meeting of the CDC's Advisory Committee on Immunization Practices (ACIP).

Overall, the school's varicella vaccination coverage was 97% among 758 children and 41% of the vaccinated children had received two doses. The CDC was invited to investigate the outbreak in order to confirm varicella in the children who had received two doses of the vaccine and to characterize the vaccine's effectiveness among one- and two-dose recipients. “Disease in vaccinated persons is generally mild, with fewer than 50 lesions and a shorter duration of illness,” noted Ms. Lopez.

For purposes of the investigation, a varicella case was defined as an acute macular papular vesicular rash without another apparent cause. Because of the frequency of insect bites in the region of the outbreak, a child needed at least three lesions to be considered a case.

A total of 27 cases were sampled for testing. Six of these were confirmed as positive using five polymerase chain reaction tests on lesion samples and one using an IgM serum spot test. The positive results for the PCR tests included one child who had received two doses of vaccine, three children who had each received single doses, and one unvaccinated child who had a history of varicella. The positive IgM serum spot test was used for a child who had received one dose of vaccine.

In June 2006, ACIP recommended a routine two-dose varicella vaccination plan for children, with the first dose given at age 12-15 months, the second dose given at age 4-6 years, and catch-up doses given to anyone older than 6 years.

Varicella cases associated with the outbreak were identified by local health data, the school nurse, and through school surveys on vaccination status and disease history. Parents of the children who were identified as cases were contacted and asked for additional information about medical history and vaccination status. Vaccination history was verified using the state's immunization registry, local health records, and the parents' surveys. Children were considered unvaccinated if they had received their first dose of vaccine 42 days or less before they became ill.

“As next steps, additional vaccine effectiveness studies for two doses are needed,” said Ms. Lopez. Data from more than 30 postlicensure studies show effectiveness estimates for a single dose of varicella vaccine ranging from 44% to 100%.

ATLANTA – Children who had received two doses of varicella vaccine comprised nearly a third of the cases in a varicella outbreak among elementary school children in Arkansas.

“This was one of the largest varicella outbreaks investigated in recent years, and it was the first U.S. outbreak reported with a significant number of two-dose vaccines,” said Adriana Lopez, an epidemiologist with the Centers for Disease Control and Prevention's division of viral diseases.

A total of 85 cases were identified during the outbreak, which occurred among children in prekindergarten through sixth grade in the fall of 2006. Of these, 25 (29%) had received two doses of varicella vaccine, 54 (64%) had received one dose, and 6 (7%) had not received any varicella vaccination. “The moderate level of two-dose coverage was insufficient to prevent the outbreak,” said Ms. Lopez, who presented the results at a meeting of the CDC's Advisory Committee on Immunization Practices (ACIP).

Overall, the school's varicella vaccination coverage was 97% among 758 children and 41% of the vaccinated children had received two doses. The CDC was invited to investigate the outbreak in order to confirm varicella in the children who had received two doses of the vaccine and to characterize the vaccine's effectiveness among one- and two-dose recipients. “Disease in vaccinated persons is generally mild, with fewer than 50 lesions and a shorter duration of illness,” noted Ms. Lopez.

For purposes of the investigation, a varicella case was defined as an acute macular papular vesicular rash without another apparent cause. Because of the frequency of insect bites in the region of the outbreak, a child needed at least three lesions to be considered a case.

A total of 27 cases were sampled for testing. Six of these were confirmed as positive using five polymerase chain reaction tests on lesion samples and one using an IgM serum spot test. The positive results for the PCR tests included one child who had received two doses of vaccine, three children who had each received single doses, and one unvaccinated child who had a history of varicella. The positive IgM serum spot test was used for a child who had received one dose of vaccine.

In June 2006, ACIP recommended a routine two-dose varicella vaccination plan for children, with the first dose given at age 12-15 months, the second dose given at age 4-6 years, and catch-up doses given to anyone older than 6 years.

Varicella cases associated with the outbreak were identified by local health data, the school nurse, and through school surveys on vaccination status and disease history. Parents of the children who were identified as cases were contacted and asked for additional information about medical history and vaccination status. Vaccination history was verified using the state's immunization registry, local health records, and the parents' surveys. Children were considered unvaccinated if they had received their first dose of vaccine 42 days or less before they became ill.

“As next steps, additional vaccine effectiveness studies for two doses are needed,” said Ms. Lopez. Data from more than 30 postlicensure studies show effectiveness estimates for a single dose of varicella vaccine ranging from 44% to 100%.

ATLANTA – Physicians now have formal approval to vaccinate HIV-exposed or HIV-infected infants and children against rotavirus.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) voted at its summer meeting to approve changes in wording to the childhood immunization schedule and endorse the use of rotavirus vaccine for HIV-infected infants and children aged 0-18 years.

Dr. Jane Seward, a member of the CDC's division of viral diseases, presented the rationale for the changes, which were approved by the committee.

“Rotavirus is a ubiquitous infection in childhood,” she said. “If these children are not vaccinated, they will almost certainly come down with wild rotavirus disease.”

Although many physicians already routinely administer the rotavirus vaccine to HIV-infected infants and children, Dr. Seward said ACIP proposed modifying the language related to rotavirus vaccination of HIV-infected children based on three main considerations:

▸ The HIV diagnosis may not be established before the age of the first rotavirus vaccine dose.

▸ Natural rotavirus infection does not appear to be more severe in HIV-infected infants.

▸ The rotavirus vaccine (RotaTeq) that would be used in HIV-positive children is attenuated considerably.

The previous wording of the childhood vaccination schedule stated that data were insufficient to support the administration of rotavirus vaccine for HIV-infected children and infants, and therefore practitioners should consider the risks and benefits before vaccinating these patients.

“So the option was there for physicians to vaccinate based on the risks and benefits,” Dr. Seward said.

Although studies in the United States are limited because of the small numbers of HIV-infected children, recent data from large studies in Africa support evidence that rotavirus disease is not more severe in HIV-positive infants and children than in those who don't have HIV, although more data are needed in older children, Dr. Seward explained.

The rotavirus vaccine is as safe as other similar vaccines given to HIV-infected children, she added. She cited the oral polio vaccine as an example; it is considered safe for HIV-infected children and replicates more quickly in the digestive tract than does the rotavirus vaccine.

No trials to assess the safety and efficacy of the rotavirus vaccine in HIV-infected children are planned for the United States, but manufacturers including GlaxoSmithKline and Merck & Co. are planning additional studies in developing countries where the burden of disease is greater, Dr. Seward said.

ATLANTA – Physicians now have formal approval to vaccinate HIV-exposed or HIV-infected infants and children against rotavirus.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) voted at its summer meeting to approve changes in wording to the childhood immunization schedule and endorse the use of rotavirus vaccine for HIV-infected infants and children aged 0-18 years.

Dr. Jane Seward, a member of the CDC's division of viral diseases, presented the rationale for the changes, which were approved by the committee.

“Rotavirus is a ubiquitous infection in childhood,” she said. “If these children are not vaccinated, they will almost certainly come down with wild rotavirus disease.”

Although many physicians already routinely administer the rotavirus vaccine to HIV-infected infants and children, Dr. Seward said ACIP proposed modifying the language related to rotavirus vaccination of HIV-infected children based on three main considerations:

▸ The HIV diagnosis may not be established before the age of the first rotavirus vaccine dose.

▸ Natural rotavirus infection does not appear to be more severe in HIV-infected infants.

▸ The rotavirus vaccine (RotaTeq) that would be used in HIV-positive children is attenuated considerably.

The previous wording of the childhood vaccination schedule stated that data were insufficient to support the administration of rotavirus vaccine for HIV-infected children and infants, and therefore practitioners should consider the risks and benefits before vaccinating these patients.

“So the option was there for physicians to vaccinate based on the risks and benefits,” Dr. Seward said.

Although studies in the United States are limited because of the small numbers of HIV-infected children, recent data from large studies in Africa support evidence that rotavirus disease is not more severe in HIV-positive infants and children than in those who don't have HIV, although more data are needed in older children, Dr. Seward explained.

The rotavirus vaccine is as safe as other similar vaccines given to HIV-infected children, she added. She cited the oral polio vaccine as an example; it is considered safe for HIV-infected children and replicates more quickly in the digestive tract than does the rotavirus vaccine.

No trials to assess the safety and efficacy of the rotavirus vaccine in HIV-infected children are planned for the United States, but manufacturers including GlaxoSmithKline and Merck & Co. are planning additional studies in developing countries where the burden of disease is greater, Dr. Seward said.

ATLANTA – Physicians now have formal approval to vaccinate HIV-exposed or HIV-infected infants and children against rotavirus.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) voted at its summer meeting to approve changes in wording to the childhood immunization schedule and endorse the use of rotavirus vaccine for HIV-infected infants and children aged 0-18 years.

Dr. Jane Seward, a member of the CDC's division of viral diseases, presented the rationale for the changes, which were approved by the committee.

“Rotavirus is a ubiquitous infection in childhood,” she said. “If these children are not vaccinated, they will almost certainly come down with wild rotavirus disease.”

Although many physicians already routinely administer the rotavirus vaccine to HIV-infected infants and children, Dr. Seward said ACIP proposed modifying the language related to rotavirus vaccination of HIV-infected children based on three main considerations:

▸ The HIV diagnosis may not be established before the age of the first rotavirus vaccine dose.

▸ Natural rotavirus infection does not appear to be more severe in HIV-infected infants.

▸ The rotavirus vaccine (RotaTeq) that would be used in HIV-positive children is attenuated considerably.

The previous wording of the childhood vaccination schedule stated that data were insufficient to support the administration of rotavirus vaccine for HIV-infected children and infants, and therefore practitioners should consider the risks and benefits before vaccinating these patients.

“So the option was there for physicians to vaccinate based on the risks and benefits,” Dr. Seward said.

Although studies in the United States are limited because of the small numbers of HIV-infected children, recent data from large studies in Africa support evidence that rotavirus disease is not more severe in HIV-positive infants and children than in those who don't have HIV, although more data are needed in older children, Dr. Seward explained.

The rotavirus vaccine is as safe as other similar vaccines given to HIV-infected children, she added. She cited the oral polio vaccine as an example; it is considered safe for HIV-infected children and replicates more quickly in the digestive tract than does the rotavirus vaccine.

No trials to assess the safety and efficacy of the rotavirus vaccine in HIV-infected children are planned for the United States, but manufacturers including GlaxoSmithKline and Merck & Co. are planning additional studies in developing countries where the burden of disease is greater, Dr. Seward said.

ATLANTA – The current vaccine financing system in the United States continues to derail vaccinations for underinsured children, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who presented results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee.

“In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults.

“Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers.

The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. The respondents cited insufficient state funding as a primary barrier to vaccination, and they reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states as FQHCs; 3 designated all public VFC providers as FQHCs; and 1 state manager designated all public and private VFC providers as FQHCs. Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said.

But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte, a family physician at the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP. Some physicians are no longer willing to incur the costs of vaccination and are sending children to public clinics, he observed.

For the most current information about coverage, billing, and policies, visit the FQHC Web site at www.cms.hhs.gov/center/fqhc.asp

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA – The current vaccine financing system in the United States continues to derail vaccinations for underinsured children, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who presented results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee.

“In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults.

“Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers.

The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. The respondents cited insufficient state funding as a primary barrier to vaccination, and they reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states as FQHCs; 3 designated all public VFC providers as FQHCs; and 1 state manager designated all public and private VFC providers as FQHCs. Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said.

But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte, a family physician at the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP. Some physicians are no longer willing to incur the costs of vaccination and are sending children to public clinics, he observed.

For the most current information about coverage, billing, and policies, visit the FQHC Web site at www.cms.hhs.gov/center/fqhc.asp

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA – The current vaccine financing system in the United States continues to derail vaccinations for underinsured children, based on new survey data from state immunization program managers.

“Limitations in 317 funding and state funding are clearly contributing to this gap,” said Dr. Grace M. Lee of Harvard University, Cambridge, Mass.

“For example, we estimate that about 3.9 billion children are unable to receive Menactra in the private sector and 1.1 billion are also unable to receive Menactra in the public sector,” said Dr. Lee, who presented results from a study of states' vaccine financing activities at a meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

The explosion in the number and cost of vaccines for children and adolescents in recent years prompted the study. In 1985, there were 7 vaccines in the routine childhood and adolescent immunization schedule; in 1995, there were 10; and in 2006, there were 16, said Dr. Lee.

“In 1985, it cost $45 to fully vaccinate a child. In 2006, the estimated cost to vaccinate a female child is approximately $1,200,” she said.

Many underinsured children must pay out of pocket for vaccines. Alternatively, private providers may refer them to the public sector to receive vaccines purchased by the state government with 317 funds or through the federally funded Vaccines for Children (VFC) program. But neither of these sources has kept up with the growth in recommended vaccinations.

The Section 317 program is a discretionary federal grant given to each state (plus all U.S. protectorates, territories, and six cities) to be used for vaccines for underinsured children and adolescents who do not meet the criteria for the VFC program or whose parents or guardians can't afford the out-of-pocket costs for full vaccination. Most of the Section 317 funds are used for routine childhood and adolescent vaccinations, although any remaining funds can be used to pay for vaccinations for underinsured adults.

“Historically, vaccines weren't so expensive, but now it is getting harder to vaccinate all children with everything due to a lack of increase in 317 funding,” Dr. Lee commented.

Dr. Lee and her colleagues conducted a two-phase study that included qualitative interviews with 48 state immunization program managers followed by a national survey and interviews with the state managers plus two city immunization program managers.

The survey and interview questions asked how and whether the cities and states provided vaccines to underinsured children, Dr. Lee said.

Overall, about 50% of underinsured children could not be vaccinated in their medical homes unless they could pay out of pocket, according to the survey results. The meningococcal vaccine (Menactra) was the least-covered vaccine. Menactra was not covered by private providers in nearly 70% of states in the study and it was not covered in public clinics in approximately 40% of the states. Of note, the ACIP recently recommended expanding meningococcal vaccination to include all adolescents aged 11-18 years.

The survey respondents expressed discomfort at having to turn away children who could not afford to pay for new vaccines, Dr. Lee noted. The respondents cited insufficient state funding as a primary barrier to vaccination, and they reported using several strategies to address the lack of funds.

A total of 27 states' managers reported limiting provider vaccine choice, and 25 used annual state appropriations to address financing limitations. A total of 13 managers reported expanding their definitions of federally qualified health care centers (FQHCs) so more underinsured children would be eligible for the VFC program. In addition, 11 managers reported negotiating state contracts with vaccine manufacturers, 9 reported decreasing their purchases of adult vaccines, and 4 reported designating annual health plan appropriations.

Of the 13 states that reported expanding FQHC designations, 9 designated some public VFC providers in their states as FQHCs; 3 designated all public VFC providers as FQHCs; and 1 state manager designated all public and private VFC providers as FQHCs. Dr. Lee said in an interview that she was unable to disclose which states had expanded the FQHCs because the interviewees' names were kept confidential.

In particular, the strategy of expanding FQHC designations to improve access for VFC patients could help relieve the increased stress of paying for vaccines for children, Dr. Lee said.

But the study did not address the other side of vaccine financing–reimbursement–which remains a hot-button issue for physicians.

“All is not well in the realm of private providers,” Dr. Jonathan Temte said during the discussion period following the presentation. “A bigger issue is reimbursement. Even if a vaccine is covered you won't necessarily get paid for all your expenses,” said Dr. Temte, a family physician at the University of Wisconsin, Madison, and the American Academy of Family Physicians' liaison to ACIP. Some physicians are no longer willing to incur the costs of vaccination and are sending children to public clinics, he observed.

For the most current information about coverage, billing, and policies, visit the FQHC Web site at www.cms.hhs.gov/center/fqhc.asp

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA – Concerns about removing financial barriers to childhood vaccination took center stage at an immunization congress sponsored by the American Academy of Pediatrics and the American Medical Association, Dr. Walter Orenstein reported at the summer meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

One focus of the congress was on recommendations that could be implemented within existing legislation, said Dr. Orenstein, who currently heads a program for vaccine policy and development at Emory University in Atlanta and is a former director of the CDC's National Vaccine Program.

At the meeting, he presented a summary of the recommendations adopted at the congress for improving financing for pediatric immunization. The recommendations remain under consideration by the National Vaccine Advisory Committee; no official document has been produced.

Barriers to adequate vaccine financing include underinsurance, lack of reimbursement, and concerns about vaccine cost, storage, and handling.

But resolving the financial barriers is not enough to ensure high childhood vaccination coverage, and private and public collaboration in vaccine delivery should be maintained, Dr. Orenstein emphasized.

“The best way to ensure continued private sector participation is to [ensure] not only reimbursement for what they do but some reasonable return on the investment beyond cost,” he said.

The congress attendees included approximately 150 representatives from medical and health societies, private providers, insurers, employers, vaccine manufacturers, the federal government, and state and local governments. They agreed that vaccines are different from other disease prevention measures because vaccines protect other members of society in addition to the vaccinees. Consequently, every state must address the financing problem to prevent the development of large clusters of unvaccinated persons, who could spread disease.

Dr. Orenstein presented recommendations from the congress that could guide the medical community's efforts to improve pediatric vaccine financing:

▸ Work with Federally Qualified Health Centers to delegate authority to public health clinics to vaccinate underinsured children through the Vaccines for Children program. This strategy would reduce some pressure on the limited Section 317 funding.

▸ Obtain data on the actual costs of delivering vaccines in private practice settings, so all medical societies could use this data to advocate with insurers for adequate reimbursement.

▸ Work with manufacturers to get better deals for vaccines, especially for new vaccines that cost more up front.

▸ Combine the resources of the American Academy of Pediatrics, American Academy of Family Physicians, and American Medical Association to define the CPT codes for adequate vaccination reimbursement.

▸ Create tax credits for insurers and providers to eliminate underinsurance. The congress attendees agreed that more work was needed to evaluate whether tax incentives would be feasible and help to immunize more children.

▸ Convene a working group to determine whether a federal purchase of vaccines or universal federal funding is worth pursuing.

▸ Acquire the data from the Centers for Medicare and Medicaid Services that were used to develop the current flu vaccine administration fees. If these rates are published and distributed, physicians can use them to advocate for higher fees for other vaccines.

▸ Collect data on the true cost of acquiring and administering combination vaccines. The Advisory Committee on Immunization Practices supports the use of combination vaccines rather than single vaccines whenever possible, but data are needed to show that combination vaccines cost more to administer than do single vaccines and should be reimbursed accordingly.

▸ Obtain data on the best business practices that minimize costs related to vaccines and vaccination, and distribute this information to health care providers.

ATLANTA – Concerns about removing financial barriers to childhood vaccination took center stage at an immunization congress sponsored by the American Academy of Pediatrics and the American Medical Association, Dr. Walter Orenstein reported at the summer meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

One focus of the congress was on recommendations that could be implemented within existing legislation, said Dr. Orenstein, who currently heads a program for vaccine policy and development at Emory University in Atlanta and is a former director of the CDC's National Vaccine Program.

At the meeting, he presented a summary of the recommendations adopted at the congress for improving financing for pediatric immunization. The recommendations remain under consideration by the National Vaccine Advisory Committee; no official document has been produced.

Barriers to adequate vaccine financing include underinsurance, lack of reimbursement, and concerns about vaccine cost, storage, and handling.

But resolving the financial barriers is not enough to ensure high childhood vaccination coverage, and private and public collaboration in vaccine delivery should be maintained, Dr. Orenstein emphasized.

“The best way to ensure continued private sector participation is to [ensure] not only reimbursement for what they do but some reasonable return on the investment beyond cost,” he said.

The congress attendees included approximately 150 representatives from medical and health societies, private providers, insurers, employers, vaccine manufacturers, the federal government, and state and local governments. They agreed that vaccines are different from other disease prevention measures because vaccines protect other members of society in addition to the vaccinees. Consequently, every state must address the financing problem to prevent the development of large clusters of unvaccinated persons, who could spread disease.

Dr. Orenstein presented recommendations from the congress that could guide the medical community's efforts to improve pediatric vaccine financing:

▸ Work with Federally Qualified Health Centers to delegate authority to public health clinics to vaccinate underinsured children through the Vaccines for Children program. This strategy would reduce some pressure on the limited Section 317 funding.

▸ Obtain data on the actual costs of delivering vaccines in private practice settings, so all medical societies could use this data to advocate with insurers for adequate reimbursement.

▸ Work with manufacturers to get better deals for vaccines, especially for new vaccines that cost more up front.

▸ Combine the resources of the American Academy of Pediatrics, American Academy of Family Physicians, and American Medical Association to define the CPT codes for adequate vaccination reimbursement.

▸ Create tax credits for insurers and providers to eliminate underinsurance. The congress attendees agreed that more work was needed to evaluate whether tax incentives would be feasible and help to immunize more children.

▸ Convene a working group to determine whether a federal purchase of vaccines or universal federal funding is worth pursuing.

▸ Acquire the data from the Centers for Medicare and Medicaid Services that were used to develop the current flu vaccine administration fees. If these rates are published and distributed, physicians can use them to advocate for higher fees for other vaccines.

▸ Collect data on the true cost of acquiring and administering combination vaccines. The Advisory Committee on Immunization Practices supports the use of combination vaccines rather than single vaccines whenever possible, but data are needed to show that combination vaccines cost more to administer than do single vaccines and should be reimbursed accordingly.

▸ Obtain data on the best business practices that minimize costs related to vaccines and vaccination, and distribute this information to health care providers.

ATLANTA – Concerns about removing financial barriers to childhood vaccination took center stage at an immunization congress sponsored by the American Academy of Pediatrics and the American Medical Association, Dr. Walter Orenstein reported at the summer meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

One focus of the congress was on recommendations that could be implemented within existing legislation, said Dr. Orenstein, who currently heads a program for vaccine policy and development at Emory University in Atlanta and is a former director of the CDC's National Vaccine Program.

At the meeting, he presented a summary of the recommendations adopted at the congress for improving financing for pediatric immunization. The recommendations remain under consideration by the National Vaccine Advisory Committee; no official document has been produced.

Barriers to adequate vaccine financing include underinsurance, lack of reimbursement, and concerns about vaccine cost, storage, and handling.

But resolving the financial barriers is not enough to ensure high childhood vaccination coverage, and private and public collaboration in vaccine delivery should be maintained, Dr. Orenstein emphasized.

“The best way to ensure continued private sector participation is to [ensure] not only reimbursement for what they do but some reasonable return on the investment beyond cost,” he said.

The congress attendees included approximately 150 representatives from medical and health societies, private providers, insurers, employers, vaccine manufacturers, the federal government, and state and local governments. They agreed that vaccines are different from other disease prevention measures because vaccines protect other members of society in addition to the vaccinees. Consequently, every state must address the financing problem to prevent the development of large clusters of unvaccinated persons, who could spread disease.

Dr. Orenstein presented recommendations from the congress that could guide the medical community's efforts to improve pediatric vaccine financing:

▸ Work with Federally Qualified Health Centers to delegate authority to public health clinics to vaccinate underinsured children through the Vaccines for Children program. This strategy would reduce some pressure on the limited Section 317 funding.

▸ Obtain data on the actual costs of delivering vaccines in private practice settings, so all medical societies could use this data to advocate with insurers for adequate reimbursement.

▸ Work with manufacturers to get better deals for vaccines, especially for new vaccines that cost more up front.

▸ Combine the resources of the American Academy of Pediatrics, American Academy of Family Physicians, and American Medical Association to define the CPT codes for adequate vaccination reimbursement.

▸ Create tax credits for insurers and providers to eliminate underinsurance. The congress attendees agreed that more work was needed to evaluate whether tax incentives would be feasible and help to immunize more children.

▸ Convene a working group to determine whether a federal purchase of vaccines or universal federal funding is worth pursuing.

▸ Acquire the data from the Centers for Medicare and Medicaid Services that were used to develop the current flu vaccine administration fees. If these rates are published and distributed, physicians can use them to advocate for higher fees for other vaccines.

▸ Collect data on the true cost of acquiring and administering combination vaccines. The Advisory Committee on Immunization Practices supports the use of combination vaccines rather than single vaccines whenever possible, but data are needed to show that combination vaccines cost more to administer than do single vaccines and should be reimbursed accordingly.

▸ Obtain data on the best business practices that minimize costs related to vaccines and vaccination, and distribute this information to health care providers.

The Centers for Disease Control and Prevention's updated recommendations for the 2007-2008 flu season emphasize vaccinating health care personnel and catching up previously unvaccinated children aged 6 months to 8 years with two doses of vaccine.

The CDC's Advisory Committee on Immunization Practices (ACIP) has published its updated flu vaccination recommendations for the 2007-2008 flu season in the Morbidity and Mortality Weekly Report (2007;56 [RR-6]:1-40). The updates include:

▸ For health care administrators. Treat the vaccination of health care personnel as a patient safety issue and encourage all health care providers to get flu shots.

▸ For physicians. In addition to those who were not previously vaccinated, children aged 6 months to 8 years who received only one dose of flu vaccine in earlier years should receive two doses this year. Administer a second dose of the trivalent inactivated influenza vaccine (TIV) at least 4 weeks after the first dose. Physicians who are using the live, attenuated influenza vaccine (LAIV) for these children should give a second dose at least 6-10 weeks after the first.

The TIV may be used for any person aged 6 months and older, including those with high-risk conditions. The LAIV is approved only for healthy, nonpregnant individuals aged 5-49 years. The influenza vaccine for the 2007-2008 season contains a new strain called A/Solomon Islands/3/2006 (H1N1)-like, and two strains used in previous vaccines: A/Wisconsin/67/2005 (H3N2)-like and B/Malaysia/2506/2004-like viruses.

Vaccination coverage continues to fall short of the CDC's recommendations, and the CDC encourages physicians to be proactive about vaccinating their patients. The updated recommendations will be posted at www.cdc.gov/flu

The Centers for Disease Control and Prevention's updated recommendations for the 2007-2008 flu season emphasize vaccinating health care personnel and catching up previously unvaccinated children aged 6 months to 8 years with two doses of vaccine.

The CDC's Advisory Committee on Immunization Practices (ACIP) has published its updated flu vaccination recommendations for the 2007-2008 flu season in the Morbidity and Mortality Weekly Report (2007;56 [RR-6]:1-40). The updates include:

▸ For health care administrators. Treat the vaccination of health care personnel as a patient safety issue and encourage all health care providers to get flu shots.

▸ For physicians. In addition to those who were not previously vaccinated, children aged 6 months to 8 years who received only one dose of flu vaccine in earlier years should receive two doses this year. Administer a second dose of the trivalent inactivated influenza vaccine (TIV) at least 4 weeks after the first dose. Physicians who are using the live, attenuated influenza vaccine (LAIV) for these children should give a second dose at least 6-10 weeks after the first.

The TIV may be used for any person aged 6 months and older, including those with high-risk conditions. The LAIV is approved only for healthy, nonpregnant individuals aged 5-49 years. The influenza vaccine for the 2007-2008 season contains a new strain called A/Solomon Islands/3/2006 (H1N1)-like, and two strains used in previous vaccines: A/Wisconsin/67/2005 (H3N2)-like and B/Malaysia/2506/2004-like viruses.

Vaccination coverage continues to fall short of the CDC's recommendations, and the CDC encourages physicians to be proactive about vaccinating their patients. The updated recommendations will be posted at www.cdc.gov/flu

The Centers for Disease Control and Prevention's updated recommendations for the 2007-2008 flu season emphasize vaccinating health care personnel and catching up previously unvaccinated children aged 6 months to 8 years with two doses of vaccine.

The CDC's Advisory Committee on Immunization Practices (ACIP) has published its updated flu vaccination recommendations for the 2007-2008 flu season in the Morbidity and Mortality Weekly Report (2007;56 [RR-6]:1-40). The updates include:

▸ For health care administrators. Treat the vaccination of health care personnel as a patient safety issue and encourage all health care providers to get flu shots.

▸ For physicians. In addition to those who were not previously vaccinated, children aged 6 months to 8 years who received only one dose of flu vaccine in earlier years should receive two doses this year. Administer a second dose of the trivalent inactivated influenza vaccine (TIV) at least 4 weeks after the first dose. Physicians who are using the live, attenuated influenza vaccine (LAIV) for these children should give a second dose at least 6-10 weeks after the first.

The TIV may be used for any person aged 6 months and older, including those with high-risk conditions. The LAIV is approved only for healthy, nonpregnant individuals aged 5-49 years. The influenza vaccine for the 2007-2008 season contains a new strain called A/Solomon Islands/3/2006 (H1N1)-like, and two strains used in previous vaccines: A/Wisconsin/67/2005 (H3N2)-like and B/Malaysia/2506/2004-like viruses.

Vaccination coverage continues to fall short of the CDC's recommendations, and the CDC encourages physicians to be proactive about vaccinating their patients. The updated recommendations will be posted at www.cdc.gov/flu